1. National Hospice and Palliative Care Organization Palliative Care Resource Series Should our Hospice Provide Palliative Care? Conducting an Organizational Assessment Gretchen Brown, MSW former President and CEO of Hospice of the Bluegrass

2. Objectives
Discuss the potential benefits to a hospice offered by a palliative care program
Describe the importance of a needs assessment when considering palliative care services
Compare potential palliative care program models
Identify financial considerations when implementing a palliative care program

3. Hospice as the Palliative Care Provider
A successful palliative care program depends upon
Sufficient community need
Adequate financial resources
Ample clinical resources and clinical expertise

4. Hospice- the Ideal Provider of Palliative Care
Hospices:
Understand palliative care concepts and interventions
Are experienced at discussing pt/family end-of-life wishes
Can describe advantages and disadvantages of treatments
Are certified and specially trained to care for patients who are appropriate for palliative care
Have experience providing care in a variety of settings

5. Is Palliative Care Needed in my Community?
Conduct a Needs Assessment/Feasibility Study
Type of palliative care program
Adequate staffing and financial resources
Internal staff discussion of pros and cons
Involve administrative and clinical leaders
Medical director
Financial staff
Representatives from partners or potential partners
Form a planning committee!

6. Program Development Investigate potential program models
Develop a list of community programs already offering services
Investigate potential program models
Determine capacity and resources of hospice provider
Examine financial and budget issues required to develop, grow and sustain
Uncover additional helpful resources

7. Program Development: Community Programs
History
Competitors were few when hospices began to offer palliative care
Hospitals provided in acute care setting
Today
Palliative care offered by most hospitals
Some hospitals provide palliative home care
Many nursing homes, home health agencies, private physician practices, insurance companies provide palliative care

8. Program Development: Community Programs
Potential patients
PACE programs
Transitions programs
Private or institutional case management programs

9. Program Development: Community Programs
Evaluate available services
History
Competence
Community reputation
Location
Is there a gap in services? Where?

10. Program Development: Investigate Program Models
Inpatient acute care model using one to a full range of palliative providers in a hospital setting
Outpatient model providing services in a skilled nursing facility or patients’ homes
Independent clinic or palliative medicine practice

11. Program Development: Determine Capacity
Identify knowledge deficits
Advanced clinical knowledge of aggressive treatment for diseases
Understanding of operation, regulations and goals of different settings
Home
Hospital
Nursing facility
Long term acute hospital
Challenge of 24 hour on call services

12. Financial Considerations: Hospices
Palliative care programs – decrease cost of care for medically complex patients
Payment to hospice organization is limited
Medicare Part B and insurance payment
Physicians and nurse practitioners
Other billable physician extenders
Social workers in some outpatient settings
Hospitals, insurers and managed care may have special arrangements

13. Financial Considerations: Healthcare Systems
Hospices within healthcare systems – easier time funding palliative care program
In system ‘credit’ for cost savings/cost avoidance to overall system can fund new program
Examples:
Kaiser – multi-state entity serves as healthcare provider and insurer
Mt. Carmel in Columbus, Ohio
Sharp system in San Diego, California
Sutter in the Bay area
Comprehensive systems in which health system owns the continuum of acute care, home care and hospice

14. Financial Considerations: Collaborative Models
Health system funds palliative care
Supports large percentage or entire program
Offers subsidies for visits
Collects for billable service or allows hospice to do so (subtracting the billings)
Healthcare system may provide non billable staff or contract from the hospice
Can be effective for acute care, home and clinic models
Can break even!
Example- Hospice of the Bluegrass

15. Financial Considerations: Fee for Service, Per Diem or Capitated Rate
Partner with large insurance company
Insurance company agrees to pay for service, per diem or capitated rate for home based palliative care
Creative Programs – Hospice of Michigan’s @HOMe
Developed contracts supplying adequate number of patients and payment
System for evaluating the savings generated to health system

16. Financial Considerations: Fee for Service, Per Diem or Capitated Rate
Medical homes
Contract with hospice organizations to provide palliative care to patients where capitated rates are common.
Stable base for homecare program
Dependable partner – insurer, union, Accountable Care Organization
Income and referral stream

17. Hospice as the Palliative Care Provider
Most difficult model to sustain
Inpatient programs may breakeven if enough consults
Travel for homecare erodes limited patient billing

18. Analyzing the Demand and Making the Budget
Knowledge about patients or beneficiaries
Value of cost avoidance
palliative care program reduces costs
prevents inpatient admissions
leads to earlier hospice admissions
Volume of services to estimate income and expenses

19. Analyzing the Demand and Making the Budget
To do’s for the hospice
Obtain Medicare Part B billing number
Billable practitioners need to be credentialed with other payers (Medicare and private insurers)
Payments vary
Setting where service is rendered
Type of service
Type of visit
Duration of visit
Number and type of each visit will need to be estimated

20. Analyzing the Demand and Making the Budget
To Do’s for the Hospice
Calculate difference between cost and income
Initially bottom line will be negative!
Determine if deficit will be offset by
Service differentiation
Partnership or customer development
Potential for additional patients
Potential for increased length of stay

21. Other Considerations Pilot programs
Help determine potential success of new program
Inpatient program – one service or one floor in a facility for specified time
Home based program – 20 referrals from hospital or insurer
Help staff understand strengths and weaknesses
Reveal unexpected challenges and opportunities

22. Other Considerations State and federal regulations
Impact how program is organized and implemented
Legal advice from healthcare attorney early in planning process
Hospice can benefit from partner’s legal counsel – should also have its own

23. Other Considerations Additional resources
Philanthropic support for startup and ongoing
Family
Healthcare systems
Community foundations
Educational resources
Hired consultant

24. Conclusion
Hospice organizations are ideal palliative care providers and partners
Education and planning are key to deciding to provide palliative care
Only if quality services can be provided at a cost that does not negatively affect the hospice!